Failure to Follow Dietitian Recommendations and Notify Physician for Significant Weight Loss
Penalty
Summary
The facility failed to follow the registered dietitian's (RD) recommendations and did not notify the physician regarding a resident who experienced a significant, unplanned weight loss. The resident, who had diagnoses including schizoaffective disorder, muscle weakness, obesity, and type 2 diabetes mellitus, was on a consistent carbohydrate diet. Over a six-month period, the resident lost 10.29% of her body weight, with meal consumption records indicating she typically ate only 51-75% of her meals. Despite the RD's repeated recommendations in March and April to liberalize the resident's diet to a regular diet to provide more calories and protein, the resident continued to receive the carbohydrate controlled diet. The clinical record did not contain documentation that the physician was notified of the significant weight loss or the RD's recommendations, nor was there an order to change the resident's diet or any indication that the physician declined the recommendation. Interviews with facility staff confirmed that the RD communicated her recommendations to the interdisciplinary team (IDT) via email and documented them in the electronic medical record, but the DON was unaware that the resident's diet had not been changed. The facility's policy required a multidisciplinary approach to nutritional assessment and intervention, but this process was not followed in this case.